Results from an 18 country cross-sectional study examining experiences of nature for people with common mental health disorders

The study investigates whether and how people currently experiencing common mental health disorders (CMDs: depression and/or anxiety) are motivated to visit, actually visit, and emotionally benefit from contact with natural environments (green and blue spaces). Prior research shows nature contact is linked to reduced risk of CMD onset, possibly due to intrinsic enjoyment and affective benefits. However, less is known about everyday motivations, practices, and experiences among those already experiencing CMDs, and whether nature contact aids symptom management and recovery. The study also examines whether perceived social pressure to visit nature (e.g., from family, friends, or via ‘green prescriptions’) undermines intrinsic motivation and visit-related wellbeing, consistent with self-determination theory. The hypotheses were: H1a: nature time is intrinsically motivating; H1b: intrinsic motivation is lower among those with CMDs; H2: nature visit frequency is lower among those with CMDs; H3a/H3b: recent blue space visits are associated with high happiness and low anxiety; H3c/H3d: those with CMDs report relatively lower happiness and higher anxiety on visits; H4a–H4d: greater perceived social pressure relates to lower intrinsic motivation, less frequent visits, lower happiness, and higher anxiety, with potential moderation by CMD status.

Evidence indicates contact with green and blue spaces reduces psychological distress and may lower antidepressant prescriptions. Experimental studies suggest nature walks benefit individuals with CMDs more than urban walks. ‘Green/blue care’ interventions (e.g., horticultural therapy, care farming, outdoor swimming, surfing) show promise but often rely on small, self-selected samples, raising questions about acceptability and generalisability. Motivational deficits in depression and experiential avoidance in anxiety can hinder engagement with activities, potentially limiting nature visitation despite intrinsic appeal. Self-determination theory suggests external pressure can undermine intrinsic motivation, shifting reasons for engagement from enjoyment to meeting others’ expectations, potentially increasing anxiety. These literatures motivate examining everyday nature-related motivations, practices, experiences, and the role of perceived social pressure among those with CMDs using a large, multi-country sample.

Design and ethics: Cross-sectional secondary analysis of the BlueHealth International Survey (BIS); ethical approval from University of Exeter College of Medicine and Health Research Ethics Committee (Ref: Aug16/B/099). Data and setting: BIS sampled adults in 18 regions: 14 European countries (Bulgaria, Czech Republic, Estonia, Finland, France, Germany, Greece, Italy, Ireland, Netherlands, Portugal, Spain, Sweden, United Kingdom), plus Canada, Queensland (Australia), Hong Kong (China), and California (USA). Administered online via YouGov panels; sampling adhered to industry standards. Full methodology available on OSF. Sampling: Approximately 1,000 respondents per country/region, representative by sex, age, geography (total n = 18,838). Four seasonal waves (June 2017–April 2018) to reduce seasonality. Analyses used YouGov weights for selection, non-response, and population biases. Measures: - CMD indicator: Self-reported doctor-prescribed medication use in past two weeks for ‘depression’ (antidepressants) and/or ‘tension and anxiety’ (anxiolytics) from EHIS. Groups: depression only; anxiety only; both; none. One case missing. - Intrinsic motivation: Single item adapted from exercise motivation: “I find visiting green and blue space enjoyable or fun” (1–7). ‘Unsure’ coded missing (n=187). - Nature visits ≥ once/week: Frequency of recreational visits to green/blue spaces in last 4 weeks (4-category). Collapsed to binary: ≥ weekly vs < weekly. Missing n=5. - Blue space visit wellbeing: For most recent blue space visit in last 4 weeks (79.4% visited; n=14,973): happiness and anxiety items (1–7), adapted from OECD experiential wellbeing. Missing: happiness n=7; anxiety n=8. - Perceived social pressure (PSP): Single item: “I sometimes feel pressured by others (e.g., partner, friends) to visit green and blue spaces” (1–7). ‘Unsure’ coded missing (n=1,038) plus 1 missing. Covariates: Sex, age group, perceived financial strain, employment, marital status, children in household, long-term limiting illness, smoking, alcohol use, seasonal wave, and country (UK reference). Visit-related models additionally adjusted for companions, dog presence, transport mode, travel time, visit duration, and prior-day happiness/anxiety. Analyses: One-sample t-tests assessed H1a and H3a/b versus scale midpoints. Linear regressions estimated continuous outcomes (intrinsic motivation; happiness; anxiety). Logistic regression estimated ≥ weekly visits. Moderation by PSP tested via inclusion of PSP and CMD × PSP interactions (H4). Country included as fixed effects. Variance inflation factors showed no multicollinearity. SPSS v25 used. Due to PSP missingness, analytic samples were: n=17,570 for intrinsic motivation and weekly visits; n=14,012 for visit happiness; n=13,975 for visit anxiety. Fully adjusted models reported; un/partially adjusted models in Supplementary Tables S5–S8.

Sample characteristics: 14% reported a CMD via medication use (n=2,698): depression only n=911 (4.8%); anxiety only n=1,013 (5.4%); both n=775 (4.1%). Descriptives (weighted means unless stated): - Intrinsic motivation (1–7): overall M=5.80 (SD=1.36), significantly above midpoint 4 (t(18,837)=181.60, p≤0.001, d=1.32). Group means: none 5.85; depression 5.64; anxiety 5.45; both 5.57. - ≥ weekly nature visits: overall, majority in each group visited ≥ weekly. Group proportions: none 58.9%; depression 53.5%; anxiety 61.3%; both 50.9%. - Happiness on last blue visit (1–7): overall M=5.81 (SD=1.11), above midpoint (t(14,972)=199.36, p≤0.001, d=1.63). Group means: none 5.83; depression 5.69; anxiety 5.57; both 5.76. - Anxiety on last blue visit (1–7): overall M=2.15 (SD=1.44), below midpoint (t(14,970)=-157.49, p<0.001, d=-1.28). Group means: none 2.07; depression 2.41; anxiety 2.70; both 2.70. - Perceived social pressure (1–7): M=2.41 (SD=1.79), below midpoint. Model 1 (without PSP; adjusted): - Intrinsic motivation: lower vs none for depression (B=-0.14, 95% CI -0.23 to -0.05, p=0.002), anxiety (B=-0.33, -0.42 to -0.25, p<0.001), both (B=-0.24, -0.34 to -0.14, p<0.001). Supports H1a and H1b. - ≥ weekly visits: anxiety more likely than none (OR=1.19, 95% CI 1.02–1.38, p=0.026); depression (OR=1.03, 0.88–1.20) and both (OR=1.00, 0.85–1.19) not different. Contrary to H2. - Happiness last visit: anxiety lower (B=-0.17, -0.24 to -0.10, p<0.001); depression similar (B=-0.04, p=0.325); both higher (B=0.10, 0.01–0.19, p=0.031). Partly contradicts H3c. - Anxiety last visit: higher for all CMD groups vs none: depression (B=0.17, 0.07–0.28, p=0.001), anxiety (B=0.20, 0.11–0.30, p<0.001), both (B=0.24, 0.12–0.35, p<0.001). Supports H3d. Model 2 (with PSP and interactions; adjusted): - Intrinsic motivation: PSP associated with lower intrinsic motivation (B=-0.09 per unit PSP, -0.10 to -0.08, p<0.001), supporting H4a. Depression × PSP interaction negative (B=-0.06, -0.10 to -0.01, p=0.022), indicating a stronger reduction with pressure among those with depression. Anxiety × PSP and both × PSP not significant. - ≥ weekly visits: PSP slightly increased odds among those without CMDs (OR=1.02, 1.00–1.04, p=0.050), contradicting H4b. Anxiety × PSP significant (OR=1.11, 1.02–1.20, p=0.012), indicating greater likelihood of ≥ weekly visits with higher PSP among those with anxiety; depression and both interactions not significant. - Happiness last visit: PSP associated with lower happiness across all groups (B=-0.04 per unit, -0.05 to -0.03, p<0.001); no significant CMD × PSP interactions, supporting H4c. - Anxiety last visit: PSP associated with higher anxiety among those without CMDs (B=0.18 per unit, 0.17–0.19, p<0.001). CMD × PSP interactions all positive and significant: depression (B=0.15, 0.09–0.20, p≤0.001), anxiety (B=0.13, 0.08–0.17, p≤0.001), both (B=0.09, 0.04–0.14, p=0.001), indicating steeper increases in visit anxiety with higher PSP among those with CMDs, supporting H4d. Overall, nature time was intrinsically motivating and associated with high happiness/low anxiety on blue space visits for all, including those with CMDs, but CMD groups showed somewhat lower intrinsic motivation, lower happiness (anxiety group), and higher visit anxiety. Perceived social pressure increased visit frequency slightly (notably for anxiety) but undermined intrinsic motivation and visit-related emotional benefits.

Findings indicate that many individuals with CMDs are intrinsically motivated to spend time in nature and frequently do so, suggesting potential self-management of symptoms via nature contact. Experiential wellbeing during blue space visits was generally positive across the population, though somewhat less positive among CMD groups (particularly elevated anxiety and lower happiness for those with anxiety). Perceived social pressure to visit nature was linked to lower intrinsic motivation and diminished emotional benefits (lower happiness, higher anxiety), consistent with self-determination theory; yet it was also associated with a modest increase in visit likelihood, especially among those with anxiety. These patterns imply that while social encouragement or ‘green prescriptions’ may prompt engagement, they risk undermining intrinsic enjoyment and may heighten anxiety during visits, particularly among those already experiencing CMDs. Potential explanations for less positive experiences include the focus on blue spaces (perceived safety risks) and environmental inequalities whereby individuals in deprived areas may access lower quality natural spaces, dampening benefits. The cross-sectional design precludes causal inference; longitudinal evaluations of green prescription programmes are needed to clarify whether pressure causes poorer experiences or whether less motivated individuals with less positive experiences feel more pressure to comply.

Many individuals with CMDs are motivated to visit nature and derive psychological benefits from such visits. However, perceived social pressure can increase visit frequency while potentially undermining intrinsic motivation and the emotional benefits of nature contact. Nature-based programmes (e.g., green prescriptions) should be designed sensitively to support autonomous motivation—potentially using techniques such as motivational interviewing—and to avoid creating perceived pressure that could diminish benefits. Improving access to higher quality natural environments and investigating setting-specific responses (green vs blue; different activity types) may enhance outcomes. Future research should use longitudinal and mixed-methods designs, incorporate objective clinical measures and severity/stage of treatment, and assess generalisability across countries and contexts.

- Representativeness: Although within-country samples were quota-representative by age, gender, and region, full national representativeness is not guaranteed; country subsamples were too small for country-specific hypothesis tests. - CMD measurement: Proxy based on self-reported doctor-prescribed medication use; cannot validate diagnosis, dosage, treatment duration, co-interventions, severity, or identify untreated CMDs or those using medications for other conditions. - Self-report and recall: All measures self-reported; potential biases in reporting CMD status and visit experiences. - Cross-sectional design: Limits causal inference, especially regarding effects of perceived social pressure. - Measurement constraints: Single-item measures for intrinsic motivation and social pressure; outcomes treated as linear although scales are ordinal; however, authors note robustness of linear models in this context. - Model explanatory power: Small to moderate R² values indicate CMD status explains a small portion of variance; many other factors are relevant. - Missing data: Particularly for the PSP item, reduced analytic samples; authors report similar composition to full sample to mitigate bias. - Focus on blue spaces for visit experiences may limit generalisability to other natural settings.